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this way was very small, as the patient experienced no alteration in his health or habits during its progress.
The cauterization may be effected by two different means ; namely, either by caustics or the actual cautery. M. Cloquet states that in the first of those cases where he attempted this method, he used, as the cauterizing agent, the acid nitrate of mercury, and succeeded completely. However, he prefers the actual cautery, its action being deeper, almost instantaneous and consequently less painful, while it occasions a more firm cicatrix, and one which becoines more rapidly organised. The three other patients were treated in this manner, and the results obtained confirmed his opinion on this point. An almost insurmountable obstacle to its employment might be, however, occasionally met with in the terror of the patient. But, fortunately, science provides us with a means of obviating this inconvenience ; as a platina wire introduced within the mouth, before the electric circuit is completed, cannot excite the patient's alarm, and as it can afterwards by this means be brought to a white heat, and be kept incandescent for any length of time, the surgeon is enabled to act with all the calmness and precision desirable.—Gazette Médicale, March 3. LITHOTOMY; SECONDARY HÆMORRHAGE ; THE ACTUAL CAUTERY.
BY MR ERICHSEN. The case was that of a man from the country, 44 years of age, and of feeble constitution, but looking much older, who had suffered from stone for several years. He was cut on the 31st of January, and a broad, flat, lithate of ammonia calculus, two inches by one and a half, removed also by the scoop. There was no hæmorrhage of any consequence at or after the operation ; but the patient complained of a good deal of pain in the wound, and fell into rather a low state. Stimulants and tonics were freely administered, and the patient went on well till the ninth day, when, as he was straining to pass a motion, very active arterial hæmorrhage suddenly occurred from the wound. The house-surgeon attempted to arrest this by plugging, but did not succeed in stopping it. Mr Erichsen coming to the hospital to make his visit about half an hour after the occurrence, cleared out the wound, and found that free arterial bleeding was occurring from its upper and anterior angles. He immediately introduced a tube and plugged the wound methodically around this. The hæmorrhage, however, continued, and it was evident that more efficient measures must be taken in order to arrest it. The tube and plugs were accordingly withdrawn, the patient brought to the edge of the bed, and chloroform having been administered, and the lower part of the wound carefully protected with wet lint held down by a spatula, the actual cautery was applied deeply towards the upper and anterior part of the inside of the wound. This immediately arrested the hæmorrhage ; but, after four days, when he was straining to pass urine, which came by the natural channel, an inconsiderable oozing occurred. This was arrested by plugging the wound with lint soaked in alum solution.
With reference to the secondary hæmorrhage, Mr Erichsen said that it was difficult to account for it, except on the supposition that the wound having been attacked by a low, hospital, sloughy form of inflammation, of the kind that had been prevalent in the hospital of late, a vessel had been opened, and thus bled freely. He remarked that he had seen several instances of secondary hæmorrhage after lithotomy-once in a private patient of his as late as the fourteenth day ; but in all these cases it had either cured of itself or had been readily arrested by plugging. In the case under consideration, however, these means were quite inadequate ; the hæmorrhage was very profuse, and would soon have exhausted the patient. Under these circumstances, there was no alternative but to apply the actual cautery. This might appear at first sight a hazardous means to be employed deeply in the wound near the neck of the bladder, but it had been followed by the best results, and had not been attended NEW SERIES.-.NO. V. MAY 1855.
by the slightest inconvenience to the patient. Mr Dalrymple, who was makin . the visit of the hospital, stated that he had known it used by his father and I Martincau at the Norwich Hospital with complete success.
In plugging the wound in order to arrest bleeding, Mr Erichsen remarked that there were two points to be looked to. One was to keep a tube in the wound and a plug around this, so as to avoid extravasation of urine; and the other, to see, although no blood might escape externally, that the bladder di not slowly fill with coagula, as would sometimes happen.-Lancet.
VESICO VAGINAL FISTULA. M. Jobert has brought under the notice of the Academy of Medicine at Paris an interesting case of this affection, in which, by his auto-plastic method of operating (separation of the vagina at its junction with the neck of the uteras) he had obtained a complete cure.
The circumstances of the case were as follows:- The patient was a girl 15 years old ; by accident during a fall, a pencil had been introduced within the vagina, and penetrated into the bladder, where it speedily became encrusta! with lithates and formed the nucleus of a very large calculus. Some months afterwards this was extracted, by the vaginal operation, by a country practitioner, and, although the case was successful in other respects, the fistulous opening (for the cure of which M. Jobert had now operated) remained as the consequence.-Gazette Médicale, March 10. ON THE EMPLOYMENT OF CHLOROFORM IN THE MILITARY HOSPITALS OF THE EAST.
After the recent remarks of Dr Hall, condemnatory of the use of this remedis! agent in the hospitals at the seat of war, it affords us much gratification to ob serve the manner in which its merits, as an adjuvant in surgical operations are regarded by our allies in that quarter, and it is with the view of showing in what estimation it is held, and how nearly its mode of administration, in the French hospitals, approaches that lately recommended by Mr Syme and others in this country, that we subjoin the following remarks, extracted from the proceedings of l'Academie des Sciences, as reported in the Gazette Mdicale for March 17, 1855 :
M. Mounier states regarding this subject, that, having had six months' experience as surgeon in chief at the hospital of Dolma Bagtché, at Constantinople, during which period he had recourse to this agent many thousand times, and in slight as well as in very serious cases, he has the satisfaction of being able to announce that the inhalation of chloroforin was universally attended with the most complete success.
The apparatus which he employed for the purpose of exhibiting the drug was extremely simple-consisting of a cone of paper, wide enough at its base to include the mouth and nostrils, and truncated at its apex with the intention of allowing a certain amount of air to enter at each inspiration. A small quantity of “charpie” was introduced within the cone, and twenty or thirty drops of chloroform poured upon this, and having previously bandaged the eyes of the patient, and enjoined strict silence, the apparatus was applied-nearer and nearer the face as the anesthesia manifested itself-until sensibility appearing absent upon pinching the skin, and intelligence upon repeating questions, the silence of the patient was regarded as the signal for commencing the operation. If the operation were a tedious one, a second or third supply of chloroform was added, which was inspired each time similarly to the first dose, alternately approaching and withdrawing the cone from the mouth of the patient during the first few seconds of inhalation.
Such was the method employed in the case of all the wounded brought to this hospital after the battles of Alma and Inkermann, and not only was there immunity from any fatal result, but there was not even any untoward symptoms demanding treatment. The safety and efficiency of chloroform as an anesthetic, M. Mounier mainly ascribes to its method of administration, that
method being in accordance with the theory advanced by M. Flourens, viz.,that this agent acts in a progressive manner, and that different stages of anæsthesia successively exhibit themselves under its action; first intelligence, then sensibility, and lastly locomotion, being brought under its influence, orto speak anatomically-its effects are observed first upon the cerebral lobes, next upon the cerebellum, and afterwards on the spinal cord. According to a number of experiments made under his own direction and superintendence, M. Mounier is of opinion that there is no necessity for continuing the administration of chloroform until the cessation of all movements. When struggling occurs during the inhalation, he contends that the removal of the apparatus from the face is sufficient for its arrestment; and in all cases he considers it a serious matter, in the use of anæsthetics, to overstep the boundary which separates abolition of sensation from abolition of motion.
INTENSE PAIN IN THE FOOT, LASTING SEVERAL YEARS, CURED BY REMOVAL OF • AN OSSEOUS GROWTH FROM THE INTERIOR OF THE POPLITEAL NERVE. BY
MR QUAIN. Elizabeth M-4, aged 32, was admitted into University College Hospital, September 9th, 1845. She is married, has had two children, the second in July of the present year; she is of fair complexion and nervous temperament. A little time ago she was received as an out-patient, on account of intense pain in the sole of her foot, at its fore-part, beneath and behind the toes. The first feeling of pain occurred about six years ago, when a little twitching was felt at the inner side of the foot. At that time the pain lasted a few minutes only at each seizure, but it soon used to last for an hour and upwards, and the duration has gradually increased till it came lately to be constant, not ceasing night or day. At first the patient could, by an effort of the will, divert her attention from the pain, and when occupied, she used for awhile to forget it; but during the last four months she has been wholly unable to do so ; indeed, she states that during those months she has not slept. She has not suckled either of her children, there never having been, according to her own statement," an appearance of milk.” A variety of treatment was resorted to before the patient applied to this hospital. She had taken many medicines during several years at home and from different hospitals, but of all of them she says that only one seemed to have any influence over the pain—that was arsenic. When that medicine was used for a time, the pain ceased during two or three weeks; then, however, it returned again as bad as before, and the arsenic failed to have any beneficial effect. Having observed at the time that the woman was to all appearance in health, and that, likewise, she was an active-minded energetic person, most anxious to get relief, and to do all that might be thought necessary to effect it, he (Mr Quain) thought it likely that there should be a local cause that is to say, an appreciable local cause for the great suffering the woman had so long experienced, and he determined to examine the limb from the spine to the toes. In the appearance of the limb there was nothing noteworthy, and during the manipulation of the foot and leg nothing unwonted was discovered; but while pressure was made upon the back part of the thigh, in the course of the large nerves, a tumour not discernible upon the surface, was discovered. It was situated at two inches distance above the level of the upper end of the patella, and being covered by one of the two hamstring muscles, was but indistinctly felt; still, when the muscles were relaxed, the outline was pretty well made out, but its consistence could not be determined, on account of the thick covering of muscle. Pressure over the tumour gave rise to the usual pain in the sole of the foot. Here, then, obviously was the real disease. It may be worth mentioning that there was no more than a soreness in the seat of the tumour, and that only when it was pressed on. The patient now, for the first time, upor being questioned, mentioned that she felt a soreness when this part was accidentally struck, even before the pain arose in the foot ; and she added that, about three years before her coming to the hospital, on pressing against the part, she felt a small lump. At that time, too, the pressure was, she recollected, accompanied with pain in the foot. He decided on laying bare the tumour, and, if possible, separating it from the nerve. It was with a view to the ope ration that the patient was admitted into the hospital.
Operation. When one of the hamstring muscles had been turned aside, the tumour came into view. It seemed an enlargement of the nerve, the internal popliteal (posterior tibial), immediately after its separation from the grest sciatic. The enlargement did not affect the nerve equally all around; it projected almost altogether on the deeper side. Upon the surface the nerve-fibres were seen to pass uninterruptedly on; the tumour was therefore within. To reach it, the strands or funicula were separated by division, longitudinally, of the connecting cellular structure, and when they had been turned aside freely, the subjacent mass was pushed out without any difficulty. None of the nerve fibres were injured. The tumour, which seemed a mass of bone, was grooved partially upon the surface from the fibres of the nerve ; it was the size and shape of a good-sized walnut, weighed 228 grains, and when analyzed was found by Mr Campbell to consist of phosphate and carbonate of lime, with a trace of sulphate of lime. It was not examined microscopically. On the day after the operation there was some local inflammation, accompanied with fever ; but in a couple of days this subsided, and the patient left the hospital in a short time entirely relieved. There remained only a little numbness in the cicatrix when it was pressed on.—Lancet.
EXTRACTION OF FOREIGN BODIES FROM THE ESOPHAGUS. M. Nelaton has collected with care the various modes of procedure for the extraction of foreign bodies arrested in the æsophagus, and he in particular examines the mode of extracting fish-hooks, the removal of which is a matter of great difficulty. In speaking of æsophagotomy, this skilful surgeon pra poses a proceeding which, according to him, is simpler than any other operation. Instead of making a lateral incisioni, M. Nelaton divides the integuments in the median line, as is done in tracheotomy, but making a more extended incision; he then separates to the same extent the sterno-hvoid muscles, so that they can be drawn apart hy blunt hooks, or, if necessary, divided transversely, in order to give more space; that done the isthmus of the thyroid body is laid bare; beneath it is passed a blunt needle, carrying a double thread, in order that two ligatures may be applied ; between the two ligatures the isthmus of the thyroid is divided. The trachea being thus laid bare, the left lobe of the thyroid is separated from it by a blunt instrument, keeping, at the same time, close to the trachea ; at the bottom of this cleft, between the trachea and thyroid, the cesophagus is necessarily found, and is to be opened in the ordinary way. By acting thus, all risk of wounding the large vessels of the neck is avoided, and the operation may be performed without injuring the thyroid arteries.-Elem. de Path. Chir. and New York Jour. of Med.
DISLOCATION OF THE NAVICULAR BONE. Professor R. W. Smith exhibited a cast of a foot, representing a luxation upwards of the navicular bone. The patient, an adult male, met with the accident while riding: the horse fell with him, and lay across his foot, which remained entangled in the stirrup. No effort was made to replace the bone, as the man did not apply for professional assistance until it was too late to reduce the displaced bone.
The features of the injury consisted in a projection, at the inner edge of the dorsum of the foot in front of the head of the astragalas, and a remarkab flattening of the plantar region ; the sole of the foot had become perfectly flat. The accident occurred several years since, and the man now enjoys the uni paired use of the limb. The partial displacement of the navicular and cuboio bones upwards has been described by Liston, but the preceding case furnishes
the first recorded instance of the luxation of the navicular bone alone.Pathological Society of Dublin.
DISLOCATION OF THE ASTRAGALUS BACKWARDS AND INWARDS. BY PROFESSOR
= PROFESSOR WILLIAMS said he would communicate to the Society a case of
dislocation of the astragalus backwards, by reading the notes of the case taken
by Mr Alfred H. Taylor, who was resident pupil at the City of Dublin Hospital - at the time of the patient's admission.
Stephen Phillips, labourer, aged 54, of spare habit and sallow complexion, but who has uniformly enjoyed good health, and lived well and temperately, was admitted into the City of Dublin Hospital on the 12th of April 1852.
He states, that on the previous day he had been at work, along with some other men, beneath an overhanging bank of earth and gravel in the granite quarry at Kingstown, which they were undermining and removing in order to expose the granite strata underneath. At the time the accident occurred, the patient and another man were engaged shovelling the loose earth, as it was detached, into a truck or waggon, which was placed behind them on the “tramway." Whilst thus employed, another man ascended the bank, and without any warning to those below, struck a heavy iron bar, called a “ clay-bar," into its upper surface, when it suddenly gave way, and being precipitated over, struck the patient violently on the left side of thorax (he was on the side of the waggon nest the falling earth), he standing with his chest parallel with the front of the bank previous to its fall ; but, when struck, his body was partially rotated backwards, and to the right side, as he was in the act of throwing a shovelful of earth into the waggon, which stood behind and to the right side of him. The force of the concussion threw him violently backwards across the roadway. The remainder of the earth fell over the lower part of his body, fixing his feet and legs to the ground. Though very much hurt, he says he was not at all confused, and describes the accident as having taken place exactly as above stated. He also says, that he does not think the mere weight of the falling earth was sufficient to produce the injuries received, as he was easily able to withdraw the injured limb without assistance ; the right leg having been more heavily covered, had to be dug out before he could be completely extricated. He says he suffered acute pain in the left ankle from the moment of the accident, and it soon became swollen, and he also had severe pain in the left side of the chest. He was carried to a house in the neighbourhood, and the next day was admitted to the City of Dublin Hospital, under the care of Dr Williams.
He complained of pain and a stitch on taking a full inspiration, in the left side of the chest, and, on examination, the fifth and sixth ribs of the left side were found to be fractured about their centres. The left ankle-joint presents some curious and unusual appearances. The anterior relations of the tibia are very little disturbed, the anterior aspect of the foot being free from deformity, except indeed a nearly imperceptible shortening of the foot, which is a little everted. He has free motion of his toes, and some slight motion of the ankle-joint. Motion of the latter increases the pain, which is of a “burning" character. There is no fracture of either the tibia or the fibula, and there is some swelling and ecchymosis, with a hard tumour of an irregularly convex shape, lying between the inferior extremity of the tibia, the tendo-Achillis, and os calcis. Professor Williams came to the conclusion that this tumour was formed by the astragalus, which was dislocated backwards and inwards, and also so rotated on its antero-posterior axis, that its superior articulating surface looked almost directly inwards. A slight attempt was made to replace the bone, but was speedily abandoned, both because of the impediment to reduction presented by the above-mentioned rotation, and of the risk of further injury to the swollen and ecchymosed soft parts covering the astragalus. The limb was then placed